Low health-related quality of life is associated with a poorer prognosis for patients with HIV, Dutch investigators report in the January 15th edition of Clinical Infectious Diseases.
“Our findings suggest that health-related quality of life could be used to assess the prognosis among HIV-infected patients in conjunction with demographic and clinical variables”, comment the investigators, “these results might be of interest to both resource-rich and resource-poor countries.”
Antiretroviral therapy can significantly improve the prognosis of HIV-infected individuals. However, currently available anti-HIV drugs are not able to eradicate the virus from a patient. Moreover even though modern HIV treatment is potent, easy to take and generally safe, it can nevertheless adversely affect an individuals’ health-related quality of life as therapy it is life-long and can cause unpleasant side-effects.
Evidence from a number of other disease areas suggests that health-related quality of life can have an impact on survival. However, there is little research exploring the relationship between this measure and the prognosis of patients with HIV.
Investigators from the national Dutch HIV ATHENA Cohort therefore designed a study to see if health-related quality of life affected the life-expectancy of 560 individuals who were about to start or who were already taking combination HIV treatment in the period 1998 to 2000. Mortality in these patients was monitored to the end of March 2008.
Using a specially designed questionnaire, the patients’ self-perceived health-related quality of life was measured in ten areas. These included pain, physical functioning, role functioning and health perceptions. The patients’ mental health was also assessed using a separate questionnaire.
Results were scored on a scale from zero to 100. The higher the score, the better a patient’s health-related quality of life. The results were stratified into quartiles, with the first quartile having the lowest score and the fourth the highest.
The investigators also obtained details on the patients’ social and demographic backgrounds, as well as their CD4 cell count on entry to the study and when HIV treatment was started, viral load, and HIV treatment history and outcome.
Most of the patients (76%) were gay men and 83% were from the Netherlands. The investigators suggest that this was a potentially a limiting factor of their research.
The median CD4 cell count at the time HIV treatment was started was 210 cells/mm3, at which time median viral load was 83,000 copies/ml.
Antiretroviral therapy was already being taken by 72% of individuals when they were recruited to the study.
By the end of follow-up in March 2008, 66 patients (12%) had died.
Mortality was related to health-related quality of life. Patients with scores in the lowest quartile had a mortality rate of 20%, compared to a rate of 13% for the second quartile, 8% for the third quartile and 4% for the highest quartile. These differences were significant (p < 0.001).
Patients with poorer mental health scores were more likely to die than those reporting better quality of life in this area (11%, lowest quartile score vs. 8% highest quartile), but the difference was not significant.
Causes of death were diverse, but a third of all mortality was attributed to HIV-related illness, with heart and lung diseases being the second most common cause of death (11%), followed by non-HIV-related cancers (9%).
When the investigators looked at their results more closely, they found that poorer health-related quality of life in the following areas were associated with an increased risk of death: physical functioning (p < 0.001), pain (p < 0.001), role functioning (p < 0.001), social functioning (p = 0.01), and general health (p = 0.01).
The investigators also found that patients who failed to provide answers to questions on a number of measures also had an increased risk of death. These were cognitive function (p = 0.01), health distress (p = 0.03), vitality (p = 0.03), pain (p = 0.04) and mental health (p = 0.05).
Statistical analysis showed that each five point increase in health-related quality of life significantly reduced the risk of death (HR = 0.8; 95% CI: 0.7-0.9).
Amongst the factors independently associated with an increased risk of death were older age, a CD4 cell count below 200 cells/mm3 when HIV treatment was started, and a detectable viral load on entry to the study.
“Patient-reported health-related quality of life was a significant and independent predictor of survival among HIV-infected patients receiving highly active antiretroviral therapy [HAART]”, comment the investigators, “the physical component of health-related quality of life remained a significant predictor even after adjusting for demographic and clinical factors.”
The investigators suggest that measuring self-reported health status is important because it “may capture the entire range of symptoms, including subtle signs of disease progression.”
“Physical health-related quality of life predicts survival in the long term in a population of HIV-infected patients receiving HAART independent of demographic or clinical variables”, conclude the authors. They suggest that this information could be useful for physicians when deciding when to initiate antiretroviral treatment.
de Boer-van de Kolk IM et al. Health-related quality of life and survival amongst HIV-infected patients receiving highly active antiretroviral therapy: a study of patients in the AIDS Therapy Evaluation in the Netherlands (ATHENA) Cohort. Clin Infect Dis 50: 255-63, 2010.